Five spine surgeons discuss the biggest challenges facing the surgeons today.
Frank M. Phillips, MD, Minimally Invasive Spine Institute at Rush: What we have witnessed over the past few years is a systematic effort to marginalize physicians and reduce their decision-making abilities in an attempt to have others dictate and thereby ration health care under the guise of "reigning in costs." Spine surgery is discretionary with large up-front costs making us an easy target. In order to accomplish these goals, spine surgeons have been portrayed as largely providing non-evidence based care to "fatten their wallets" without regard for patients well being. Physicians have inaccurately been singled out as the major drivers of costs of healthcare. As a consequence of this insidious attack on spine surgery, spinal surgical decision-making is increasingly dictated by bottom-line driven insurance companies using non-transparent, non-validated guidelines as an opportunity to deny spinal care.
Over the past decade, a wealth of quality spinal data has been published supporting good clinical outcomes and cost-effectiveness for spinal fusion surgery for a host of diagnoses. However, with the shift of decision-making power away from spine surgeons, emboldened payers selectively ignore or cherry pick studies or data to suite their ultimate goal — reducing costs and driving profits.
This message was brought home when on a recent call a physician reviewer (a retired obstetrician) informed me "his company had a policy of a blanket denial of all lumbar fusions." These types of intrusions into the doctor-patient relationship and decision-making are our greatest challenge to providing our patients with the best evidence-based care. Addressing this will likely require a combination of continuing to gather validated evidence, a more active and coordinated effort by our spinal organizations and a patient and public advocacy push.
Mick Perez-Cruet, MD, Chief of Minimally Invasive Spine Institute, Beaumont Hospitals, Royal Oak, Mich.: I think the most challenging issue for spine surgeons today is keeping up with the expenses of clinical practice while providing high quality, cost effective spine care in an environment of flat or declining reimbursement for services provided.
Raj Rao, MD, Director of Spine Surgery, Medical College of Wisconsin, Milwaukee: There are probably two issues that spine surgeons are most concerned with these days:
1) Increasing regulation of the practice of medicine by the governmental regulatory agencies, as well as by insurance companies. While some oversight and regulation is good for our patients, there comes a time when the increasing burden of this regulation harms rather than helps our patients. Fulfilling multiple mandatory requirements or checking multiple boxes on the computer screen takes time away from the interaction with our patients, reduces patient satisfaction and at some point possibly even diminishes healthcare outcomes.
2) Decreasing reimbursement for the services we provide our patients. This appears to be affecting not just the governmental payers, but private insurance reimbursement as well. The economic, social and personal cost of providing care remains unchanged. At some point along the curve of decreasing reimbursement there comes a time when physicians will stop seeing patients from some payer groups, and our concern is that access to care for these patients will be diminished.
Jeffrey Goldstein, MD, Director of Spine Service, NYU Hospital for Joint Diseases, New York City: There are many challenges facing healthcare providers today. Our goal is to provide the best outcomes for our patients while responsibly utilizing limited resources. There is a balance between what "we know" and what we "believe." Additionally we are expected to provide our care within an increasingly cost-conscious environment.
We are asked to develop and rely on outcome studies. Part of this requires we provide what we believe are the best options for our patients and continue to advocate on their behalf. Payers may challenge and question our recommendations which we believe benefit our patients despite our having data which supports our experience.
Terrence Crowder, MD, Sonoran Spine Center, Mesa, Ariz.: The most challenging issue facing spine surgeons is the uncertainty of the future of medicine. The entire landscape of medicine is changing. Physicians and patients are anxious about 
coming changes. Will the millions being spent on ICD-10 and electronic health records actually improve care? How much will reimbursements be reduced? Will more surgeries be denied? Will rising deductibles result in fewer people seeking care? Will private practice physicians be forced into hospital employment?
These are only a few of the questions we face. Medicine has become as volatile as the stock market. Medicine is difficult enough without the added pressures we now face. Hopefully, over the next few years things will stabilize. However, I think most surgeons would agree that we are in for quite a ride.
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